Head of internal medicine at Klerksdorp’s Tshepong Hospital Ebrahim Variava may be one of a dying breed of doctors – unafraid to speak out against a broken public health sector, and a doctor whose passion for patients is as fiery as his bright red scrubs, who works “outside the box” to ensure they get the right care.
For 20 years, Tshepong Hospital has punched above its weight. Once the last choice of medical interns, today it’s a popular option, thanks in part to the University of the Witwatersrand (Wits) Medical School having added Tshepong as a satellite hospital in 2003.
It was one of the first public facilities to launch an HIV programme, which became one of the country’s busiest and most innovative, and its drug-resistant TB unit has participated in a roll-call of important global TB studies.
Many contributed to the rise of Tshepong, but the ongoing tenure of Variava straddles this relatively golden era, writes Sean Christie for Bhekisisa.
He’s one of few doctors working in the public health system who consistently speaks out about important issues like stockouts of essential medicines or the effects of violent strikes on patient care.
For most, this would be career foreshortening – in fact in June 2020, he was suspended without warning after internally criticising his hospital’s Covid-19 strategy, triggering a public stand-off between the provincial Health Department and fellow research collaborators and colleagues, who organised a petition. Variava beat the odds, and returned to work.
Judging from his tone while speaking on the phone as he enters his office, Variava’s zeal for frank talk is undiminished.
“Call me Brimey,” he says. “I’m quite pissed off.”
Touch and gos
At issue is the case of a patient he’s just seen. “He had an abnormal X-ray last year but it wasn’t followed up. He kept coming back, but we have these chaotic issues where files get misplaced and new files keep getting made. So that’s what I’ve been doing today: trying to get all the files together to figure out what’s going on with him.”
As his investigations progressed, Variava realised he knew the patient.
“It’s someone who came here when I started in Tshepong in 2001. He had a cardiac problem and needed a double valve replacement. He used to drive a tambai (a local term for a community taxi) and the kind of service they provide is amazing: they will bring in disabled people from their homes to the hospital, something other public transport options cannot do.
“His operation was very successful, and he used to hoot and wave whenever he saw me. But I haven’t seen him for some years – he’s had other doctors. Now it appears he has this lung malignancy, which has simply been missed, and it seems to have progressed.
“I had to explain this to him and apologise and … he took it amazingly well. He said, ‘No, it’s not your fault, it’s a problem with the files, we understand things like that.’ I don’t know that I’d be as kind. His case illuminates a series of issues in hospitals, like awful filing systems, and the lack of ability to deliver continuity of care.”
Variava has a name for public service doctors: he calls them “touch and gos”.
“They touch the life of a patient – and disappear. It’s a problem in our public system. We get a lot of good doctors, but they rotate through the different departments and there’s no continuity of care. This is exactly what I’ve seen today.”
Outspoken
Variava was born in Fietas in the centre of Johannesburg, the “laatlammetjie” among seven – six boys and one girl.
Variava is 22 years younger than his oldest sibling, Yosuf “Joe”, who devoted his life to serving the public health system, and to defend medical ethics. In 1985, Yosuf led what became known as the “Steve Biko court case” against the SA Medical and Dental Council, which resulted in disciplinary action against the doctors who attended to the dying Biko and misrepresented the causes of his injuries.
Variava’s third oldest sibling, Haroun, went into exile in the UK in 1977, and was part of the Black Consciousness Movement there. His fourth brother, Sadecque, was involved in the founding of the SA Students Organisation and the Black People’s Convention, and was tried in the “Black Consciousness trial”.
“Our family life was often shattered by the appearance of the police… I was suspended in 2020, because it similarly happened without warning. I was outside the ICU teaching young doctors about ventilation and the management of Covid-19, and people from HR and labour relations came with this suspension letter and told me to leave immediately – no finishing what I was doing.”
An inability to tolerate bullying
In 1987, Variava and other black medical student activists made life difficult for the dean of the Wits medical school, Clive Rosendorff, by refusing to train in research hospitals designated whites-only, after being told they should ask female patients for their consent before examining them, while white doctors were not expected to do the same.
Variava later did his internship at Johannesburg’s Coronation Hospital (now Rahima Moosa) in 1992, where he met and began dating Dezlyn, who was studying ultrasonography.
Working outside the box
In 1993, the couple moved to deeply rural Shongwe, near the borders of South Africa, Swaziland (eSwatini) and Mozambique. Variava had taken a job as a medical officer, overseeing 16 clinics.
“It was an amazing time. I would drive through beautiful scenery with the Lebombo Mountains nearby, as far as Mbuzini, where Samora Machel’s plane came down and where they used to deliver babies by the light of kerosene lamps,” he recalls. He shared a house with a team from Médecins Sans Frontières, who were attending to refugees from the civil war in Mozambique.
“It was from their guys that I learned about care groups. Their doctors noticed many kids were suffering from kwashiorkor. Even though they would address the issue, the patients would return with the same problem.
“So they created a nutritional rehabilitation unit at the hospital, and started teaching the children’s caregivers how to grow beans and other protein sources. The kids started to do well. They took these mothers to the local clinics to provide training for other mothers, who went back to their villages to teach women there how to provide appropriate nutrition. There was a sudden drop in case numbers, and I became interested in how you can use people to improve things for the community.”
After specialising in internal medicine Variava joined Leratong Hospital in Krugersdorp. He was on call every weekend, and burnt out.
“At that point I sold my soul,” he says.
“A friend who worked for Anglo American came to me and said, ‘Anglo is not a bad health service, and you can make a change.’
“I had bought a house, we had just had a child, and the salary was double what I’d been getting, so I took the job, in Welkom. I learned a fortune: about mining, lung disease and silicosis, about TB. But there were some things I didn’t like,” says Variava, who used to get letters from the mine managers asking him to either book his patients off permanently or clear them for work.
“I would write back and say I’m not a mechanic employed to fix tools to go back underground. I’m here to help my patients if I can.”
He was also disturbed by the company’s approach to cryptococcal meningitis, a brain fungus that is, after TB, one of the top killers of people with advanced HIV.
“After diagnosing it we were expected to fill in a terminal leave form and the person would be cut from the workforce and sent home without treatment. They felt that the drug for treating it – fluconazole – was unaffordable. But the manufacturer, Pfizer, had donated a quantity of this drug to the state, so instead of filling out the terminal leave form, I would send my patients to the public hospital for treatment, to a friend who was working there.
“When management figured this out they called me to a table and drew me a box and said, ‘We need you to work within this box.’ I said, ‘No, you guys may pay me, but I work for the patient. If the solution doesn’t lie within your box, I’m going to push it out.’
“Well, they pushed me to resign and I did… I was emotionally stuffed from having to watch the awful natural life cycle of cryptococcal meningitis again and again, without being able to do anything about it.”
Patients the priority
On the day he resigned, Variava received a call from his former family physician, Hamid Wadee.
“He had moved to Klerksdorp and was the superintendent of Tshepong Hospital. He asked me if I wanted a job as a senior specialist. I was offered the position of principal specialist, and took it.”
The North West Province MEC for Health was Molefo Sefularo, who stuck his neck out allowing Variava to set up an HIV clinic at a time when “the national Minister was up to crap, espousing garlic as an Aids cure”.
“He said, ‘Go ahead, just don’t make a noise’, and that’s how we started,” recalls Variava, who established one of the most innovative HIV programmes in SA, working with Francois Venter and the Reproductive Health & HIV Research Unit (at Wits) to train clinic nurses to start patients on antiretrovirals.
A long-time collaborator of Variava’s, Neil Martinson, says he was “impressed by Brimey’s can-do attitude” when he first met him in 2007.
“He was enthusiastically diagnosing and treating people with HIV, and had these innovative research ideas, based on clinical experience in wards treating critically ill patients. This prompted us (the Wits Perinatal HIV Research Unit) to do our first collaborative study at Tshepong,” says Martinson.
One of those ideas was a strategy for referring HIV patients to general practitioners (GPs) in private practice for their ongoing treatment and care, and paying them to do this.
“Actually, it was similar to some of what the government wants to do with NHI. We pitched the idea to the US-based BroadReach Group and they liked it and funded it. The programme ran for about eight years with 20 participating GPs and more than 5 000 patients. When the results came in they were unheard of: retention in care at about 97%, and 93% of patients in the cohort had undetectable viral loads,” says Variava.
The Health Department declined to take over the programme, after initially promising to do so, though.
“There was a change of leadership. Priorities shifted,” he says.
“This place isn’t what it once was – the brass things no longer shine as they used to. We have three CT (computerised tomography) scan machines, but often there’s no toilet paper or too few blankets. Everything is going down. In my view, the early cadres were a bit more committed, because they were fresh from the struggle. But lately it’s just vulgar self-interest in every direction. I am tired,” he admits.
“I draw strength from the young doctors coming through – they keep you alive, even if they do watch movies on their phones.”
Before leaving Variava’s office, I notice a device on the table.
“It’s a portable ultrasound device I bought from the US. It has transformed how I practise medicine,” he says, and demonstrates, by percussing my chest – the difference between the old way of checking for pneumonia, and what his sonography machine can do with far greater precision.
“They’re made by a company called Butterfly IQ, which is on a mission to democratise healthcare. I believe in this. I mean, doctors have been stuck with the stethoscope since the French Revolution. This (thing) gives us eyes, it gives us vision.”
Bhekisisa article – The importance of being Brimey (Creative Commons Licence)
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NW Health makes U-turn on controversial suspension of Prof Variava
Suspended Prof ‘acted in a manner suspicious of unapproved research’
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